[104-10222-10005.pdf — page 285]
# DECLARATION OF APPOINTEEThis form is to be completed before entrance on duty. Answer all questions. Admitted unfavorable information about such matters as arrests or discharges will be considered together with the favorable information in your record in determining your present fitness for Federal employment. However, a false statement or dishonest answer to any question may be grounds for dismissal after appointment and is punishable by law.1. PRESENT ADDRESS (street and number, city and State)5006 Columbia Pike, Apt 3 Arlington, Virginia(A) DATE OF BIRTH (B) PLACE OF BIRTH (city and State or city and foreign county)29 June 1930 Fond du Lac, Wisconsin3. (A) IN CASE OF EMERGENCY, PLEASE NOTIFY (B) RELATIONSHIP (C) STREET AND NUMBER, CITY AND STATE (D) TELEPHONE NO.Mrs. Margaret Keenan Wife 5006 Columbia Pike, TA 5-0228Apt 3 Arlington, VA4. DOES THE UNITED STATES GOVERNMENT EMPLOY, IN A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (EITHER BY BLOOD OR MARRIAGE) WITH WHOM YOU LIVE OR HAVE LIVED WITHIN THE PAST 12 MONTHS?YES NOIf yes, for each such relative fill in the blank below. If additional space is necessary, complete under Item 12.| NAME | POST OFFICE ADDRESS (Give street number, if any) | (1) POSITION (2) TEMPORARY OR NOT (3) DEPARTMENT OR AGENCY IN WHICH EMPLOYED | RELATIONSHIP | VET. PREF. DISC. (Check one) || ---- | ------------------------------------------------ | ---------------------------------------------------------------------------- | ------------ | ---------------------------- ||      |                                                  |                                                                              |              |                              ||      |                                                  |                                                                              |              |                              ||      |                                                  |                                                                              |              |                              |INDICATE ANSWER BY PLACING "X" IN PROPER COLUMN|                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        | YES | NO  | INDICATE ANSWER BY PLACING "X" IN PROPER COLUMN                                                                                                                                                                                                                                   | YES | NO  || -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --- | --- || 5. (A) ARE YOU A CITIZEN OF THE UNITED STATES OF AMERICA, OR (B) AS A NATIVE OF AMERICAN SAMOA DO YOU OWE ALLEGIANCE TO THE UNITED STATES OF AMERICA?                                                                                                                                                                                                                                                                                                                                                                                  |     | X   | 10. (A) HAVE YOU EVER FILED A WAIVER OF LIFE INSURANCE COVERAGE UNDER THE FEDERAL EMPLOYEES' GROUP LIFE INSURANCE ACT?                                                                                                                                                            | X   |     || 6. ARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE, TERRITORY, COUNTY, OR MUNICIPALITY? If your answer is "Yes," give details in Item 12.                                                                                                                                                                                                                                                                                                                                                                                                 |     | X   | (B) IF YOU HAVE FILED SUCH A WAIVER, HAS IT BEEN CANCELED OR REVOKED?                                                                                                                                                                                                             | X   |     || 7. DO YOU RECEIVE OR HAVE YOU APPLIED FOR AN ANNUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA, GOVERNMENT UNDER A RETIREMENT ACT OR ANY PENSION OR OTHER COMPENSATION FOR MILITARY OR NAVAL SERVICE? If your answer is "Yes," give details in Item 12.                                                                                                                                                                                                                                                                           |     | X   | 11. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT: A. HAVE YOU BEEN DISCHARGED FROM EMPLOYMENT BECAUSE: (1) YOUR CONDUCT WAS NOT SATISFACTORY?                                                                                                                        | X   |     || 8. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT, HAVE YOU BEEN ARRESTED, CHARGED FOR HELD BY FEDERAL, STATE OR OTHER LAW ENFORCEMENT AUTHORITIES FOR ANY VIOLATION OF ANY FEDERAL LAW, STATE LAW, COUNTY OR MUNICIPAL LAW, REGULATION OR ORDINANCE? DO NOT INCLUDE TRAFFIC VIOLATIONS FOR WHICH A FINE OF $25 OR LESS WAS IMPOSED. ALL OTHER CHARGES MUST BE INCLUDED EVEN IF THEY WERE DISMISSED. If your answer is "Yes," give in Item 12 for each case: (1) approximate date, (2) charge, (3) place, (4) action taken. |     | X   | (2) YOUR WORK WAS NOT SATISFACTORY?                                                                                                                                                                                                                                               | X   |     || 9. SINCE YOU FILED APPLICATION RESULTING IN THIS APPOINTMENT, HAVE YOU BEEN BARRED BY THE U.S. CIVIL SERVICE COMMISSION FROM TAKING EXAMINATIONS OR ACCEPTING CIVIL SERVICE APPOINTMENTS? If your answer is "Yes," give dates of and reasons for such Jobarment in Item 12.                                                                                                                                                                                                                                                            | X   |     | B. HAVE YOU RESIGNED AFTER OFFICIAL NOTIFICATION THAT: (1) YOUR CONDUCT WAS NOT SATISFACTORY?                                                                                                                                                                                     | X   |     ||                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |     |     | (2) YOUR WORK WAS NOT SATISFACTORY?                                                                                                                                                                                                                                               | X   |     ||                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |     |     | C. HAVE YOU BEEN DISCHARGED FROM THE ARMED SERVICES UNDER OTHER THAN HONORABLE CONDITIONS? If your answer to A, B, or C is "Yes," give details in Item 12 as clearly as you can remember, including the name and address of employer, approximate date, and reasons in each case. | X   |     |12. SPACE FOR DETAILED ANSWERS TO OTHER ITEMS (Indicate item numbers in which answers apply.)| ITEM NO. |     || -------- | --- ||          |     ||          |     ||          |     |INSTRUCTIONS TO APPOINTING OFFICER. - You must determine that this appointment would be in conformance with the Civil Service Act, applicable Civil Service, Rules and Regulations, and acts of Congress pertaining to appointment.This form should be checked for holding of office, pension, any record of recent discharge or arrest, age, citizenship and members of family. Also, to establish the identity of the appointee, you should particularly check (1) his signature and handwriting against the application and/or other pertinent papers and (2) his physical appearance against the medical certificate.